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TREASURY DEPARTMENT 
UNITED STATES PUBLIC HEALTH SERVICE 

HUGH S. GUMMING, Surgeon General 



THE POSTURE OF SCHOOL CHILDREN 
IN RELATION TO NUTRITION, PHYS- 
ICAL DEFECTS. SCHOOL GRADE 
AND PHYSICAL TRAINING 



BY 



E. BLANCHE STERLING 

Acting Assistant Surgeon 
United Stales Public Health Service 



REPRINT No. 779 
FROM THE 

PUBLIC HEALTH REPORTS 

August 25, 1922 
(Pages 2043-2049) 



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1922 



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OOCUMSNTii ;.iiv,;SIQ. 



THE POSTURE OF SCHOOL CHILDREN IN RELATION TO 
NUTRITION, PHYSICAL DEFECTS, SCHOOL GRADE, AND 
PHYSICAL TRAINING.^ 

By E. Blanche STERLm^,'.\*ftag 'Assistant Surgeon, United States Public Health Service. 

The importance of posture from the standpoint of health has been 
quite generally recognized since the brilliant exposition of the subject 
by Goldthwait more than a decade ago. Parents have always been 
interested in the child's posture froni the esthetic point of view, but 
it is realized that the matter has a far deeper significance than that 
which relates merely to personal appearance. The positive health 
value of good posture — to say nothing of its mental effect — is con- 
ceded to be great enough to demand careful scientific investigation 
as to the underlying causes of good and bad posture and their relation 
to the ordinary conditions of childhood. 

The exponents of some of the popular health movements are each 
prone to consider his particular activity as a panacea for all the 
bad posture in the world. This is particularly true of a certain type 
of nutrition worker, or play enthusiast, or specialist in corrective 
gymnastics. It was felt, however, that to obtain any data of value 
on the subject of posture it would be necessary to take cognizance 
not only of those matters but to consider also the hygiene of school 
life and instruction and the prevalence of common physical defects 
in childhood. 

The present study was made in three elementary schools at Bed- 
ford, Ind., comprising children in the first six grades. The number of 
sixth-grade children is small, owing to the fact that this grade was 
taught in only one of these schools. The age, sex, grade, nutrition, 
physical defects, and posture were noted in the case of practically 
every child in the group studied. 

NUTRITION AND POSTURE. 

In estimating the nutrition of these children, those who were less 
than 7 per cent under the existing standards of weight for a given 
age and height were considered to be well nourished, and were 
marked ''Good." Those 7 per cent or more below these standards 
were marked "Poor." Those who were underweight at the first 
weighing but came up to the accepted standard before the close of 
the school year, and those having "Good" nutrition at the first 
weighing but sinking to or below the 7 per cent level during the year, 

I Reprint Irom the Public Health Reports, vol. 37, No. 34, Aug. 25, 1922, PD. 2043-2049. 

10714—22 1 



2 " ■ POSTURE OF SCHOOL CHILDEElSr. 

were together given an intermediate rating as ''Fair." Posture was 
rated as "Good," ''Fair," or "Poor," according to the points usually 
considered — position of head and shoulders, antero-posterior curves 
of the spine, flexion of knees, etc. 
Table I.— Nutrition and posture rating of 1 ,115 children in three elementary schools. 



Rating. 


Nutrition. 


Posture. 


Good 


Per cent. 
58 
23 
19 


Per cent. 
29 




40 


Poor 


31 







Of a total of 1,115 children who were given a rating for posture, 
321, or 29 per cent, were classified as good; 442, or 40 per cent, as 
fair; and 352, or 31 per cent, as poor. Thus it will be seen that the 
number of children having good posture was slightly less than that of 
the children having poor posture. 

Table II. — Correlation of posture and nutrition. 
Good posture: Percent, i Poor posture: Percent. 



Good nutrition 63 

Poor nutrition 14 

Good nutrition: 

Good posture 31 

Poor posture 30 



Good nutrition 54 

Poor nutrition 23 

Poor nutrition: 

Good posture 22 

Poor posture 39 



According to those who believe that nutrition is the controlling 
factor in posture, one would expect to find a majority of these 1,115 
children undernourished. On the contrary, 58 per cent of the number 
never fell to the 7 per cent line during the whole school year, whereas 
only 19 per cent were at or below this level during the same period. 
The number of well-nourished children was twice as great as the 
number of children with good posture. With three times as many 
well-nourished children as undernourished, the number having good 
posture, instead of being three times as great, was slightly less than 
the number having poor posture. Of the 645 children well nourished 
throughout the year, 31 per cent had good posture and 30 per cent 
had poor posture. So that a child with good nutrition has a slightly 
more than even chance of having good posture. If the child's 
nutrition is poor, his chances of having good posture are less, 22 
per cent of the 212 children underweight throughout the year having 
good posture and 39 per cent having poor posture. 

Of those children who reach the good-posture grade, the well- 
nourished constitute 63 per cent of the total number. It is to be 
noted, however, that 14 per cent of these good-posture children 
were underweight throughout the year, so that it is quite possible 
for an underweight child to have good posture. On the other hand, 
among the children with poor posture, almost twice as many were 
well nourished as were undernourished — 54 per cent to 23 per cent. 



POSTUEE OF SCHOOL CHILDEEIT, 



On the whole, it seems evident that while good nutrition is a con- 
tributory factor to good posture, it is almost as likely to be found 
with poor posture. Poor nutrition is less likely to be found with 
g( od posture than is good nutrition with poor posture. 

PHYSICAL DEFECTS AND POSTURE. 

An investigation of the relation of physical defects to posture 
brought out some interesting facts. 

Table 111.— Correlation of physical defects with posture. 



Defect. 



Teeth alone 

Eyes alone and with teeth 

Adenoids alone and with teeth 

Tonsils alone and with teeth 

Adenoids alone or with eyes, teeth, or both 

Tonsils alone or with eyes or teeth or both 

Adenoids and tonsils alone or with eyes or teeth or both 

Adenoids or tonsils or both, alone, or with eyes, teeth, or both 



Number 

of 
children. 



430 
126 

35 
114 

39 
157 
188 
3S4 



Posture. 



Good. 



Per cent. 
34 
26 
14 
26 
15 
25 
23 
23 



Poor. 



Per cent. 
23 
37 
43 
36 
41 
39 
43 
41 



Defective teeth, which have been blamed for most of the ills which 
flesh is heir to, apparently can be given a comparatively clean bill 
of health in the case of posture. Of 430 children having this defect 
alone, 34 per cent had good posture and 23 per cent had poor posture. 
Since the number having good posture is almost one and one-half 
times as great as those with poor posture, defective teeth can not be 
considered a factor of importance in the production of poor posture. 

The number of children having eye defects alone (37) is too small 
to furnish any conclusive evidence as to the effect of this defect on 
posture. When, however, to this number is added those having a 
combination of eye and teeth defects, and eliminating the latter as 
unimportant, the figures show 37 per cent with poor posture as against 
26 per cent with good posture. Hence, eye defects must be taken 
into consideration in studying the question of the posture of school 
children. This evidence supports the opinions long held by ortho- 
pedists. 

Defects of the nose and throat seem to have an important effect 
on the posture of the child. Of 384 children having adenoids or 
enlarged or diseased tonsils, or both, either alone or in combination 
with eyes, or teeth, or both, 41 per cent had poor posture and only 
23 per cent had good posture. Of 306 children in whom were found 
a combination of poor posture and physical defects, 52 per cent had 
adenoids, enlarged or diseased tonsils, or a combination of these 
defects. 

It is interesting to note that of those children showing poor posture 
not accompanied by physical defects the well nourished throughout 



4 POSTURE OF SCHOOL CHILDREN. 

the year were twice as numerous as the ill nourished throughout the 
year, and also twice as many as those underweight at the beginning 
of the year but who came up to the accepted standards before the 
close of school. This is another bit of evidence that poor posture 
is by no means pathognomonic of poor nutrition. 

SCHOOL LIFE AND POSTURE. 

In order to inquire into the relation of school conditions to the 
posture of the pupils, a study was made of posture in the various 
grades. It seems scarcely fair to include the sixth grade, because 
of the small number of children of that grade included in the study, 
and hence it is omitted in the grade studies. It will be seen from 
the accompanying table that the general direction of the good pos- 
ture curve is downward from the first grade, and that of the poor 
posture curve is upward. 

Table IV. — Posture by grades. 



Grade. 


Number 

of 
pupils. 


Posture. 


Good. 


Fair. 


Poor. 


1 


358 
197 
195 
201 
125 


Per cent. 
34 
29 
28 
24 
29 


Per cent. 
40 
45 
37 
38 
33 


Per cent. 
26 


2 


26 


3 


35 


4 


38 


5.. 


38 







The difference between the highest and lowest good posture ratings 
is 10 per cent, whereas the difference between the highest and lowest 
poor posture rating is 12 per cent. The fall in good posture is seen to 
be slightly less than the rise in poor posture. These figures are 
encouraging, because, with adequate health supervision, physical 
training, and good hygienic conditions, it ought not to be difficult 
to convert a 12 per cent deficit into a good posture surplus. The 
school system studied, while having many excellent features, did not 
have an adequate system of physical training for its elementary 
schools, and the pupils at that timfe had not been furnished with 
adjustable seats and desks. 

SCHOOL GRADE AND NUTRITION. 

In order to discover whether the increase in poor posture and the 
decrease in good posture in the higher grades was accompanied by 
an increase in malnutrition in those grades, a grade-nutrition study 
was made. It would be manifestly unfair in a school-grade-nutri- 
tion study to use the results of the first fall weighing as a basis for 
the calculation of the malnutrition for that grade. The child's 
weight when he enters school in the fall is largely influenced by his 



POSTUBE OF SCHOOL CHILDREN. 



manner of life during the long summer vacation, when he is not 
directly under the school's influence. In view of this fact, the age 
weight-height index was obtained from the spring weighing. 

Table V. — Percentage nf underweight pupils by grade. 

Per cent. 

Grade 1 23 

Grade 2 17 

Grade 3 19 

Grade 4 21 

Grade 5 23 

It will be seen from the table that there was a rather sharp fall in 
the amount of underweight from the first to the second grade, and 
then a gradual rise until the percentage of underweight pupils in the 
fifth grade was exactly the same as that in the first grade. The dif- 
ference between the amount of malnutrition in the second grade 
and the fifth grade was 6 per cent. Again it is seen that the corre- 
lation between nutrition and posture is not a perfect one. 

POSTURE AND PHYSICAL EXERCISE. 

Unfortunately the school system studied furnished no real test of 
the effect of various forms of physical exercise. No trained teacher 
of physical education was connected with the elementary schools. 
The pupils were supposed to engage in supervised play during recess, 
but there was no supervision other than that of the regular class 
teacher. Without training in games and the supervision of play 
activities, her presence on the playground m most cases had no prac- 
tical value, as far as real playground work was concerned. Occa- 
sionally a teacher's enthusiasm helped to make up for her lack of 
training, but this was the exception rather than the rule. 

In two of the schools (L. and S.), in addition to this more or less 
desultory play, the teacher taught the pupils some free standing 
gymnastics. In L. school these were conducted to music, in generally 
poor form, in a hall in the center of the building, without adequate 
ventilation. At S. school rather vigorous, snappy, free-standing 
exercises were given without music, frequently in the open air when 
the weather permitted. 

A comparative study of posture in these three schools will give a 
fair idea of the value of such physical training as the pupils received. 

Table VI. — Posture, nutrition, and physical defects in three elementary schools. 



School. 


Posture. 


Nutrition. 


Physical defects. 


Good. 


Fair. 


Poor. 


Good. 


Fair. 


Poor. 


Eyes. 


Adenoids. 


Tonsils. 


S 


Per cent. 
39 
24 
21 


Per cent. 
33 
42 
45 


Per cent. 
28 
34 
34 


Per cent. 
56 
63 
53 


Per cent. 
26 
19 
25 


Per cent. 
18 
18 
22 


Per cent. 
20 
21 
23 


Per cent. 
20 
18 
24 


Per cent. 
32 


C 


29 


L 


34 







6 POSTUKE OF SCHOOL CHILDREN. 

Table VI shows that the posture rating in S. school was decidedly- 
better than that in either of the other schools. In order to eliminate 
any source of error in estimating the value of the physical training, 
the nutrition and physical defects have been included in the same 
table for the purpose of comparison. Since the nutrition in S. school 
is lower than that in C. school and the combined percentage of physi- 
cal defects is higher, the superiority of S. over C. can not be due to 
either of these factors. 

The posture ratings of C. and L. are very nearly equal, though C, 
with better nutrition and fewer physical defects, should naturally 
rate higher. It does not seem likely that the poor type of gymnas- 
tics at the L. school accounts for this difference. Whether their 
play is more worth while or the fact that the school has fewer pupils 
to handle is responsible for the condition can not be definitely stated. 

Though it is felt that the effect of play on posture did not have a 
fair test in the elementary schools, some interesting work in basket 
ball was carried on in the high school. The Bedford High School 
team proved itself to be the second best basket-ball team in the 
State of Indiana, which is fairly conclusive evidence of the thorough 
training it received. It is worthy of note that even a cursory inspec- 
tion of these boys showed some examples of fine posture. 

CONCLUSIONS. 

The posture of school children can not be said to dej>end entirely, 
or even chiefly, on any one condition. The following conclusions 
seem to be confirmed by the facts noted in this study : 

1. While good nutrition is a contributing factor to good posture, 
it is by no means an indispensable condition. 

2. Defective vision, adenoids, and bad tonsils tend to have an 
unfavorable effect on a child's posture. 

3. When the hygienic conditions in a school are not of the best, 
and health measures are inadequate, there is a moderate decrease of 
good posture and increase of poor posture from the first to the fifth 
grade, inclusive. This is not believed to be a necessary accompani- 
ment of school life, but a condition that may be easily remedied by 
cooperation of the health and educational authorities, 

4. In planning exercise with a view to the promotion of good pos- 
ture, it is suggested that setting-up exercises be simple and vigorous 
and play full of energy and vim. Formless, jellyfish gymnastics, or 
stupid, silly games, played half-heartedly, have little place in the 
proper physical development of the growing child. 

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